Free tarsal graft combined with skin transposition flap for full-thickness lower eyelid reconstruction

We present the surgical outcome in a series of 4 patients with large full-thickness eyelid defects after basal cell carcinoma excision. The patients underwent reconstructive eyelid surgery using autogenous free tarsal grafts combined with a skin transposition flap from the upper eyelid. Two female and 2 male patients ranging in age from 44 years to 85 years were treated. In all 4 cases, posterior lamellae were reconstructed using a free tarsal graft, and the outer lamella was developed with a transposition skin flap from the upper eyelid. The skin flap provided adequate vascular support in all cases. Follow up of 10 months to 20 months showed a good outcome in all patients. Reconstruction of full thickness eyelid defects after extensive tumor excision requires reforming of the anterior and posterior lamella. Whereas the Hughes or Cutler Beard techniques for eyelid reconstruction require a 2-step approach with occlusion of the eye for at least 1 week, reconstruction with a free tarsal graft is a 1-stage procedure and does not entail eye occlusion. Autogenous tarsus as a free graft proves to be a simple procedure for posterior lamella substitution in lower eyelid surgery, especially in combination with a skin transposition flap from the upper eyelid.     

Irradiated homologous tarsal plate banking: a new alternative in eyelid reconstruction. Part I. Technique and animal research

Reconstruction of full thickness eyelid defects requires the correction of both posterior lamella (tarsus, conjunctiva) and anterior lamella (skin, muscle). Tarsal substitutes including banked sclera, nasal cartilage, ear cartilage, and periosteum can be beneficial for posterior lamellar repair, while anterior lamellar replacement, including skin grafts, pedicle flaps, advancement flaps, etc., is important to cover the posterior reconstructed portion. At times, due to extensive tissue loss, the eyelid reconstruction can be particularly challenging. We have found an alternative posterior lamellar reconstructive technique utilizing irradiated homologous tarsal plate that can be particularly useful in selected cases of severe tissue loss. The experimental surgical procedure in monkeys and the histological fate of the implanted tarsus is described in Part I, and followed in Part II by our experience with this tissue in six human patients.     

“Sandwich Block” for Eyelid Reconstruction

Purpose: To report on a one-stage technique for eyelid reconstruction with preservation of the eyelid margin.

Design: Prospective study.

Methods: Five patients with small-to-intermediate full-thickness lower eyelid defects (n?=?3) and upper eyelid defects (n?=?2) after tumor excision. Defect size ranged from 5 to 7?mm vertically and from 7 to 12?mm horizontally. For eyelid reconstruction, a full-thickness pentagonal graft from the opposite lid was sutured into the full-thickness defect after removal of the orbicularis oculi muscle from the graft. The orbicularis muscle flap from the recipient eyelid was mobilized and brought in for vascular supply between tarsus and skin of the graft. The outcome after surgery was assessed using a subjective scoring system with 4 subsequent grades.

Results: At 1 week postoperatively, adequate viability of the grafts was noted in all patients. After a mean follow-up of 13 months (range 3–33 months) the cosmetic and functional outcome was adequate in 1 case, good in 2 cases, and excellent in 2 cases.

Conclusion: Reconstruction of small to intermediate full-thickness defects of both lower and upper eyelid with the “sandwich block”-technique is associated with a good functional and cosmetic outcome.     

Partial and Total Reconstruction of the Lower Eyelid

Our techniques for reconstruction of the lower lid are based on the maintenance of tarsal support in the reconstructed lid. The surgical approach is dictated by the position and extent of the defect produced by tumor excision. Lysis of the extension of the lateral canthal ligament to the lower lid allows closure of small, full-thickness defects. Mobilization of tarsal remnants by temporal advancement flaps provides for closure of larger defects. An advancement flap of split-thickness upper lid tarsus is combined with a pedicle flap of skin from the upper lid for total lower lid reconstruction.     

Reconstruction of large upper eyelid defects with a free tarsal plate graft and a myocutaneous pedicle flap plus a free skin graft

Purpose: To review and present the results of a one-step method employing a free tarsal plate graft and a myocutaneous pedicle flap plus a free skin graft for reconstruction of large upper eyelid defects after tumour surgery.Methods: This was a retrospective case-series of 8 patients who underwent reconstruction of the upper eyelid after tumour removal. The horizontal defect involved 50–75% of the lid (3 pts.), more than 75% (3 pts.), and more than 75% plus the lateral canthus (2 pts.). The posterior lamella was reconstructed with contralateral upper eyelid tarsal plate. The anterior lamella was reconstructed with a laterally based myocutaneous pedicle flap in 7 patients, leaving a raw surface under the brow which was covered with a free skin graft. In 1 patient with little skin left under the brow, the anterior lamella was reconstructed with a bi-pedicle orbicularis muscle flap together with a free skin graft.Results: All patients healed without necrosis, did not suffer from lagophthalmos, achieved reasonable cosmesis, and did not need lubricants. In one patient, a contact lens was necessary for three weeks because of corneal erosion. One patient still needs a contact lens 3 months after excision to avoid eye discomfort.Conclusion: Large upper eyelid defects can be reconstructed with a free tarsal plate graft and a laterally based myocutaneous pedicle flap in combination with a free skin graft. Two-step procedures can probably be avoided in most cases.     

硬腭黏膜移植联合眼周皮瓣修复下睑全层缺损

目的:探讨用硬腭黏膜植片修复眼睑缺损后层,眼周皮瓣修复眼睑前层缺损,这一联合手术的临床效果。方法:对8例因下睑肿瘤切除所致的下睑全层缺损,采用自体硬腭黏膜移植联合眼周皮瓣重建下睑。结果:随访8mo以上,全部病例硬腭黏膜植片及转移皮瓣全部成活,除1例下睑轻度退缩外,眼睑外观和功能满意,获得良好效果。结论:硬腭黏膜移植联合眼周皮瓣修复下睑全层缺损,可以一次性修复缺损的皮肤、睑板、结膜,效果肯定,具有较高的临床价值。     

Irradiated homologous tarsal plate banking: a new alternative in eyelid reconstruction. Part II. Human data

Reconstruction of full thickness eyelid defects requires the correction of both posterior lamella (tarsus, conjunctiva) and anterior lamella (skin, muscle). Irradiated homologous tarsal plate provides a structured framework for the lid reconstruction, and is incorporated nicely into the normal lid anatomy.     

异体睑板移植修复眼睑缺损

目的 修复21眼因各种原因所致的部分或全层眼睑缺损。方法 采用低温保存的异体睑板移植替代瞪板,内层行结膜转移或唇粘膜移植。外层应用邻近带蒂皮瓣或游离显效5眼,改善2眼,失败1眼,术后效果与血运 的好坏和移植片的大小有关。结论 采用低温保存的异体睑板修复眼睑缺损,排斥反应轻,疗效佳。是替代睑板的理想材料。     

A simple correction for congenital tarsal kink associated with distichiasis.

Congenital tarsal kink is a rare condition. The folded edge of the upper tarsus, or the inturned lashes, may traumatize the cornea causing ulceration. We describe a case of unilateral upper eyelid horizontal tarsal kink associated with distichiasis and congenital corneal ulceration. Several different surgical treatment options have been previously alluded to in the literature including lamellar tarsoplasty, full-thickness eyelid fracture, and rotation and excision of the kink with tarsal reapposition. Repair by means of eyelid everting sutures via an anterior lamellar approach is presented as a novel technique to correct this congenital anomaly.     

Surgical treatment of upper lid trichiasis with partial tarsal rotation: a new procedure

The authors' report a new surgical technique for partial isolated upper lid trichiasis. This ten minutes' time consuming procedure is easy to perform. It allows a fair cosmetic appearance of the operated eyelid and permits a reliable uneventful outcome. The technique consists to severe the lid margin and the tarsal plate on a distance of 3 to 4mm, at each part of it's trichiased area, in order to allow the pathological part of the eyelid to rotate like a shutter. The rotation of the ill eyelid segment is strengthen by a partial resection of the anterior lamella localizated here and there of the lid crease above the trichiased part of the eyelid, which allows to place everting sutures between the superior part of the tarsus and the two edges of the anterior lamella incision.     

Levator aponeurosis sandwich flap for reconstruction of upper eyelid defect

A 72-year-old woman suffered from a sebaceous gland carcinoma on her left upper eyelid. The tumour was 13 × 5 mm without metastasis. The tumour was excised with a 5-mm safety margin, resulting in a large, full-thickness defect in which almost all of the tarsal plate, approximately half of the orbicularis oculi muscle, and part of the levator aponeurosis were lost. Reconstruction of the upper eyelid was successfully performed with a levator aponeurosis sandwich flap, upon which the posterior lamella was covered by a free tarsal graft with medial and lateral periosteal flaps, and a skin graft from the contralateral upper eyelid for the anterior lamella. No lagophthalmos was demonstrated after the operation. Six months postoperatively, there was no tumour recurrence, no ocular complications, and good cosmetic results.     

Levator Aponeurosis Sandwich Flap for Reconstruction of Upper Eyelid Defect

A 72-year-old woman suffered from a sebaceous gland carcinoma on her left upper eyelid. The tumour was 13 × 5 mm without metastasis. The tumour was excised with a 5-mm safety margin, resulting in a large, full-thickness defect in which almost all of the tarsal plate, approximately half of the orbicularis oculi muscle, and part of the levator aponeurosis were lost. Reconstruction of the upper eyelid was successfully performed with a levator aponeurosis sandwich flap, upon which the posterior lamella was covered by a free tarsal graft with medial and lateral periosteal flaps, and a skin graft from the contralateral upper eyelid for the anterior lamella. No lagophthalmos was demonstrated after the operation. Six months postoperatively, there was no tumour recurrence, no ocular complications, and good cosmetic results.     

风筝皮瓣修复眼睑前层及中面部皮肤缺损

目的 评价风筝皮瓣修复合并或不合并中面部皮肤缺损的眼睑前层缺损的疗效.方法 自2008年1月至2010年3月,以面部皮下组织为蒂,设计"风筝"皮瓣,联合或不联合硬腭黏膜移植,修复合并或不合并中面部皮肤缺损的眼睑缺损共10例.眼睑前层或和中面部皮肤缺损面积为(1.2～6.5)cm2、(0.7～4.0)cm2.其中下眼睑中央水平方向4/5、垂直方向完全全层缺损合并颧颊部皮肤缺损1例,下睑内侧水平方向1/2、垂直方向完全全层缺损、下泪小点下泪小管缺损合并中面部皮肤缺损1例,下睑水平及垂直方向均完全全层缺损合并下泪小点及下泪小管缺损1例,上下睑水平方向完全、垂直方向1/3全层缺损合并上下泪小点泪小管缺损1例,下睑中央水平方向4/5、垂直方向完全全层缺损合并颧颊部皮肤缺损1例,全上眼睑前层及颞部皮肤缺损1例,下睑内侧水平方向1/3、垂直方向1/5前层缺损1例,上下睑中央水平方向2/3、上睑垂直方向1/3,下睑垂直方向2/3全层缺损1例,上下睑内侧1/3前层及内呲内侧皮肤缺损合并上下泪小点缺损1例,外眦外侧前层及颞部皮肤缺损1例.结果 皮瓣均无张力修复缺损,皮瓣及硬腭黏膜均全部成活,眼睑外形、功能完全恢复.结论 风筝皮瓣是修复眼睑缺损及面部皮肤缺损的良好方法.

Abstract：

Objective To evaluate the effect of rehabilitating the anterior 1amella of eyelids and midfacial skin defects with kite flap.Methods From January 2008 to March 2010,with or without combination of a hard palate mucosal grafts,the kite flap on a subcutaneous pedicle have been used to repair defect in the anterior lamella of eyelids and midfacial skin in 10 patients.The area of the defect in the anterior lamella of eyelids and midfacial skin ranged from(1.2～6.5)×(0.8～4)cm.Among them,defects span central 4/5 in horizontal direction and complete in vertical direction in full-thickness lower eyelid and partes zygomatica skin in 2 patient,medial 1/2 in horizontal direction and complete in vertical direction and puncta and canaliculus in full-thickness lower eyelid and midface skin in 1 patient,complete lower eyelid and inferior puncta and canaliculus in 1 patient,complete in horizontal direction and 1/3 in vertical direction and puncta and canaliculus both in full-thickness upper and lower eyelids in 1 patient,complete anterior layer of upper eyelid and temples skin in 1 patient,medial 1/3 in horizontal direction and 1/5 in vertical direction in the anterior lamella of lower eyelid in 1 patient,central 2/3 in horizontal direction and 1/3 in vertical direction in full-thickness upper eyelid,and central 2/3 in horizontal direction and 2/3 in vertical direction in full-thickness lower eyelid in 1 patient,medial 1/3 of anterior lamella and puncta and canaliculus both in upper and lower eyelid and inside skin of medial canthus in 1 patient,outside skin of outer canthus and temples skin in 1 patient.Results All flaps and hard palate mucosal grafts were survived.All defects were repaired without tention.The cosmetic appearance and function of eyelids rehabilitated.Conclusions The kite flap provides a competitive method for repairing the anterior lamella of eyelids and facial skin defects.     

The cutler-beard bridge flap technique with use of donor sclera for upper eyelid reconstruction

We evaluated the Cutler-Beard bridge flap technique with the use of donor sclera for upper eyelid reconstruction. The right upper eyelid of a 22-year-old man (case 1) was bitten by a dog. A mass in the left upper eyelid of an 85-year-old man (case 2) was excised. Major full-thickness defects of the eyelid with small loss of tarsus were reconstructed with the use of donor sclera. Good cosmetic results were obtained. Major full-thickness defects of the upper eyelid with small loss of tarsus may be effectively reconstructed by the Cutler-Beard technique with use of donor sclera.     

表浅肌肉腱膜皮瓣联合硬腭黏膜移植修复全层眼睑缺损

目的探讨利用眼周表浅肌肉腱膜系统（SMAS）皮瓣联合硬腭黏膜移植修复中、重度全层眼睑缺损的临床疗效。方法对26例（26只眼）大于或等于眼睑全长1／2的全层眼睑缺损患者,采用硬腭黏膜移植替代眼睑后层,即睑板和睑结膜层;利用眼周血供丰富的SMAS皮瓣修复眼睑前层,即皮肤肌肉层。其中5例采用眼轮匝肌蒂皮瓣,5例为颞浅动脉皮瓣,7例为眉上皮瓣,9例为上睑皮肤轮匝肌双蒂瓣。手术操作中首先行硬腭黏膜移植,然后根据眼睑前层缺损的部位和范围设计眼周的SMAS转位皮瓣,术毕行睑缘缝合3个月。结果全部患者随访6～36个月,平均11个月。转位皮瓣全部成活,硬腭黏膜植片成活好,无收缩,眼睑外观及功能改善较满意。结论眼周SMAS皮瓣联合硬腭黏膜移植可一次性修复缺损的眼睑全层,效果肯定。     

Secondary tarsoconjunctival flap after previous lower eyelid Hughes repair

PURPOSE: To describe a secondary, two-stage eyelid-sharing tarsoconjunctival flap advancement technique for the repair of full-thickness lower eyelid defect, using the remaining upper eyelid marginal tarsus that was spared in a previously performed Hughes procedure. METHODS: A computerized database search was performed on all cases of Hughes repair of the lower eyelid performed over a 10-year period (1995 to 2005) to identify patients who required a secondary tarsoconjunctival flap repair. In two cases of tumour recurrence at the lower eyelid margin, an eyelid-sharing, two-stage tarsoconjunctival flap repair of the lower eyelid using the remaining 4 mm of marginal tarsus that was spared in the original Hughes procedure was performed. Case reports of these 2 patients are presented together with their postoperative results. RESULTS: The incidence rate of the described secondary tarsoconjunctival flap procedure was 2 cases per 240 cases (0.8%) of primary Hughes procedure performed over a 10-year period. The postoperative courses in the 2 patients were uncomplicated with excellent surgical results at 6 months' follow-up. CONCLUSIONS: The secondary tarsoconjunctival flap advancement procedure is an effective reconstructive technique for the repair of the full-thickness lower eyelid defect in an eyelid that has already undergone a previous Hughes repair.     

Free tarsus autogenous graft struts for lower eyelid elevation

PURPOSE: Free tarsus autogenous graft (FTG) has emerged as a useful biological spacer in lower eyelid elevation. However, it has limited use where a spacer of greater than 4 mm height is required, because at least 4 mm of upper tarsal height must be preserved to maintain upper eyelid rigidity. We describe an augmentation of FTG in its use as a spacer, by way of creating 2 parallel-placed vertical FTG struts, in contrast to interpositioning the FTG horizontally. METHODS: This case series describes the technique of harvesting and interpositioning FTG struts. Nine eyelids in 6 patients in whom FTG struts were used for lower eyelid elevation are reported. The patients ranged in age from 41 to 80 years. Underlying diagnoses included thyroid orbitopathy, previous blepharoplasty, and previous facial and eyelid thermal burns. RESULTS: FTG struts achieved an effective spacer height of up to 7 mm, and follow-up of 9 to 20 months revealed a good outcome in all 3 cases, with no complications. CONCLUSIONS: FTG struts provide an effective and lasting lower eyelid elevation when used as a spacer. A spacer graft of up to 7 mm in vertical height may be harvested from a long strip of upper eyelid tarsus that is 4 mm in vertical height. This technique would allow autogenous upper eyelid tarsus to be harvested with maximum conservation of tissue.     

Tarsal switch procedure for the surgical rehabilitation of the eyelid and socket deficiencies of the anophthalmic socket.

PURPOSE: To describe a tarsal transfer procedure, which we have named the "tarsal switch," to correct the eyelid malpositions and camouflage the socket defects of acquired anophthalmos. METHODS: The technique consists of an upper eyelid tarsectomy, with transfer of the autologous tarsoconjunctival graft to the posterior lamella of the lower eyelid. RESULTS: The operation was performed in 21 anophthalmic patients. In 16 patients with eyelid malpositions, excellent results (within 1 mm of the fellow eye) were attained in 100% of the patients with ptosis, and in 88% of patients with lower eyelid retraction. In the remaining 5 patients, orbital volume loss with secondary implant migration, inferior prosthetic displacement and eyelid asymmetry predominated. In these patients the anophthalmic orbital defects and eyelid asymmetry were masked well. Patient satisfaction was high and complications were few during an average follow-up interval of 16 months. CONCLUSION: The tarsal switch procedure is useful in managing the eyelid malpositions and masking the orbital deficiencies of the anophthalmic socket.     

硬腭黏膜移植联合眶周表浅肌肉腱膜系统皮瓣重建全层眼睑缺损

目的:探讨利用自体游离硬腭黏膜植片替代后睑组织联合眶周表浅肌肉腱膜系统(SMAS)皮瓣转移修复缺损的前层眼睑皮肤,重建因肿瘤术后或外伤所致的全层眼睑缺损的临床疗效。方法:对16例≥眼睑全长1/2中重度全层眼睑缺损患者,全部用口腔硬腭黏膜植片替代睑板和结膜,再造后层眼睑;用眶周血供丰富的表浅肌肉腱膜系统(SMAS)皮瓣转移覆盖于硬腭黏膜上,替代缺损的眼睑皮肤肌肉层再造前层眼睑,其中10例采用眼轮匝肌单蒂皮瓣,3例为颞浅动脉皮瓣,2例为上睑皮肤轮匝肌双蒂皮瓣,1例为眉上皮瓣。手术操作中首先行硬腭黏膜移植,然后根据眼睑前层缺损的部位和范围设计眶周的SMAS转移皮瓣,手术完毕行睑缘缝合3～6mo后切开。结果:全部患者随访>12mo,硬腭黏膜植片及其转移皮瓣全部成活,无移位、感染和坏死等不良反应,无收缩,眼睑外观及功能改善满意。结论:硬腭黏膜联合SMAS皮瓣转移修复重建眼睑全层缺损,可以一次性修复眼睑缺损的皮肤、睑板、结膜,疗效肯定,具有较高的临床应用价值。     

Microscopic findings of lateral tarsal fixation in Asians

PURPOSE: To identify microscopically lateral tarsal fixation in Asians. METHODS: Specimens from 19 postmortem lateral eyelids and orbits of 11 Asians (11 right, 8 left; aged 45-96 years at death) were used. Samples damaged on sectioning and samples without tarsal plates were excluded. The samples were fixed in 10% buffered formalin and examined under a microscope. Two levels of tarsus were observed in the upper and lower eyelids, suggesting the possibility of different means of fixation. The first and second sections, which were incised parallel to the eyelid margin, were obtained at 1 mm and 5 mm from the upper eyelid margin, and at 1 mm and 3 mm from the lower eyelid margin. The sections were stained with Masson trichrome. RESULTS: The first sections of all upper eyelids and those of the lower eyelids except one showed tarsal fixation by both the lateral rectus capsulopalpebral fascia (lr-CPF) and the tendon-ligament complex of the lateral canthal tendon (LCT), which in several cases received the muscle of Riolan. The second sections of all upper eyelids showed fixation by the lr-CPF and the ligamentous part of the LCT. The second sections of the lower eyelids were mostly similar to the second sections of upper eyelids, though some showed only ligamentous fixation. The lr-CPF in all cases included a small amount of smooth muscle fibers. CONCLUSIONS: The lateral aspect of the tarsus is supported by the lr-CPF and the LCT, which in some cases includes the muscle of Riolan.